Application for a shotfirer licence - Renewal

This form is used to apply for a renewal of a shotfirer licence in accordance with Regulation 133 of the Dangerous Goods Regulations. Applicant must have attained the age of 18 Application fee: Please refer to the NT WorkSafe website for current fees and charges.

1. Current licence details Licence number: Expiry date:

Attach a copy of front and back of your NT Shotfirer licence

2. Licence type Agricultural/Seismic/Small Scale Blasting Tunnelling and underground mining Quarrying/Open Cut Fireworks (display) Construction Fireworks (special effects) Other (please specify):

3. Applicant details Surname:

Given names: Date of birth:

Residential address:

Suburb: State: Postcode:

Is your postal address the same as above? (If no, complete below) Yes No

Postal address:

Suburb: State: Postcode:

Home number: Mobile number:

Email address:

4. Medical details Do you suffer from defective hearing, defective vision or a physical infirmity which would render you unfit to safely perform the duties as a holder of the licence for which you have applied? (if yes please complete below)

Yes No

5. Employer details Current employer business name:

Supervisor name: Phone:

Previous employer business name: (if applicable)

Supervisor name: Phone:

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6. Evidence of continual useAttached Blast plans/log books; and

Employer/Supervisor to complete below stating your practical or continual experience

Supervisor name:

Supervisor signature: Date:

7. Criminal history check (please attach evidence of completed check)

Attached completed national police history name check completed

Note: If current, a current Dangerous Goods Security Card can be accepted in place of a criminal history check. All criminal history checks must not be more than 6 months old at time of application.

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8. Proof of identity (ID) Applicants must attach either one of the following combinations:

• One primary and two secondary documents; or • Two primary and one secondary documents from the list below.

ID must include at least one type of primary ID that contains the applicants name and date of birth. If you are unable to provide the required documents please contact NT WorkSafe.

Primary document Select

Australian birth certificate/card Australian passport (note: passports are still valid for 2 years after expiry, unless cancelled) Australian citizenship certificate Australian drivers licence Licence or permit issued by the Commonwealth, State or Territory government that has your DOB and photo i.e HRWL licence, working with children’s card etc

Proof of age card issued by an Australian State or Territory Identity document issued by an Aboriginal Land Council that has your photograph Secondary document Select

Photo ID card showing you are a Commonwealth, State or Territory Government employee Medicare, centrelink or health care card Credit card or debit card – one per bank only Council rates notice with your name and current residential address Utilities notice with your name and current residential address Foreign drivers licence

9. Receiving licence

How do you wish to receive the licence? Post Collection

10. Applicant declaration The information in this application is true and correct to the best of my knowledge. I consent to the Competent Authority making enquiries and exchanging information with Regulators in other States, Territories or the Commonwealth regarding any matter relevant to this application. NT WorkSafe may also disclose your licence status to third parties who wish to verify your licence. Licence status refers to the issue and expiry date as well as any classes or conditions of your licence.

Applicant name:

Applicant signature: Date:

Checklist Application form completed and signed

One passport-size photograph not more than 6 months old. Alternatively, photographs can be taken at any Territory Business Centre

Payment of application fee

Privacy statement The Department of Attorney-General and Justice complies with the Information Privacy Principles scheduled to the Information Act.

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Lodgement Complete applications can be lodged in person, email or via post at a Territory Business Centre below:

Darwin Darwin Corporate Park, Building 3, 631 Stuart Highway Berrimah NT.

Katherine Shop 1, Randazzo Building, 18 Katherine Terrace.

Alice Springs Ground floor, The Green Well building, 50 Bath Street.

Tennant Creek Shop 2, Barkly House, Cnr Davidson and Patterson Street.

Phone: 1800 193 111 Email: territorybusinesscentre@nt.gov.au Postal: GPO Box 9800, Darwin, NT 0801

Payment details Cash Cheque (Made out to Receiver of Territory Money) Credit card (Visa or MasterCard Only)

Cardholder name:

Card number: Expiry:

I hereby authorise the Territory Business Centre to debit the above credit card for the amount of $

Cardholder signature: Date: